H0060-75000-10-0073 (3/12) CLIENT: HGB ELECTROPHORESIS HBFA2 T3, FREE FRET3 HIGH SENSITIVITY CRP HSCRP T3, UPTAKE TUPT HIV I / II Ab, Ag DIAGNOSTIC HIVCD T4, TOTAL T4 HIV I / II Ab, Ag SCREEN HIVCS T4, FREE FT4 530 N.E. Glen Oak Ave. HLA B27, BLOOD HLABB TEGRETOL / CARBAMAZEPINE CRBAM Peoria, Illinois 61637 • (309) 655-2336 HOMOCYSTEINE HCY TESTOSTERONE TEST 1-800-533-6730 • FAX (309) 624-9152 Patient Information − Please Print HPV, LO/HI RISK HPVIRS TESTOSTERONE, FREE / TOTAL TESTTF PATIENT’S LAST NAME (PLEASE PRINT) IMMUNOGLOBULIN IgE IGE Ab TGAB IMMUNOGLOBULIN IgG IGG THYROGLOBULIN & THYROGLOBULIN Ab THRYG IMMUNO QT W/KAPPA, LAMBDA GAMKL TOPIRAMATE TOPAR PATIENT’S FIRST NAME M.I. DATE OF BIRTH SEX IMMUNOFIX, SERUM W/O SPE SIFE TOXICOLOGY - URINE TU / / IMMUNOFIX, SERUM, ID & QT W/SPE IFESPE TRF Patient ID No. IMMUNOGLOBULIN IgM IGM QUAD SCREEN (INCLUDE FORM) QUADSC IMMUNOGLOB QUANT (A, G, M) IGQT TSH TSH PHONE NUMBER SOCIAL SECURITY NO. INFLUENZA VIRUS A AB, IGG, IGM FLUAB VALPROIC ACID VAL INFLUENZA A & B Ag FLU VARICELLA ZOSTER IgG Ab VZOST COLLECTED DATE TIME COLLECTOR INITIALS INSULIN INS VARICELLA ZOSTER IgM Ab VZSTM AM FASTING NON-FASTING / / PM INSULIN GROWTH FACTOR 1 (IGF-1) ILGF VITAMIN A VIA STAT RESULTS ( ) - PHONE RESULTS ( ) - IONIZED CALCIUM ICA VITAMIN B1, BLOOD THIA FAX RESULTS ( ) - DATE OF SURGERY / / IRON W/TIBC FE1 VIT B6, PYRIDOXAL 5 PHOSPHATE PLPB6 ORDERING PHYSICIAN DUPLICATE REPORT TO: KOH OTHER KOHOTH VITAMIN B12 B12 KOH SKIN, NAILS, HAIR KOHP VITAMIN D, 25 HYDROXY VTMD ACE ACENZ CORTISOL CORT LAMOTRIGINE LAMI ZINC ZINCS ACTH, PLASMA ACTHA CYCLOSPORINE CYCLO LDL, MEASURED DLDL 24 HR. URINE TESTS ALDOLASE ALDS CYSTIC FIBROSIS MUT PNL CYFM LEAD, BLD (for Peds Submit Form) LEAD6 ALK PHOS ISOENZYMES ALKPTI DHEA, SULFATE AT OSF DHEAS LEGIONELLA Ag, URINE ULEG VOL: ______WT: ______ALPHA 1 ANTITRYPSIN A1AT ENA PANEL ENA LEVETIRACETAM (KEPPRA) LEVET 5-HYDROXYINDOLEACETIC ACID (5-HIAA) 5HIAA AFP NOT MATERNAL AFP ENDOMYSIAL ABS, IGA ENDMAB LH LH CALCIUM, QUANT UCA AFP-MATERNAL (INCLUDE FORM) GENOR EPSTEIN BARR COMPREHENSIVE EBVAB LIPOPROTEIN (a) APOL CATECHOLAMINE FRAC, FREE CATFF ALDOSTERONE ALLDS ERYTHROPOIETIN ERYTH LUPUS ANTICOAGULANT LUP METANEPHRINE FRACTIONATED METUQ ANA SCREEN ONLY ANAO ESTRADIOL ESTDL LYME LYME TOTAL , QUANT UP ANA SCREEN, TITER IF POSITIVE ANA ESTROGENS, TOTAL E1 + E2 ESTFR METHYLMALONIC ACID MMAQ VANILLYLMANDELIC ACID VMAU ANCA / VASCULITIDES MPOPR FACTOR 8 ACTIVITY F8 MTHFR DNA MUTATION MTH OXALATE OXUR ANTI DNA Ab, DOUBLE STRAND ADNA FACTOR 5 LEIDEN SCREEN APCR MUMPS Ab, IgG MUMG CITRATE EXCRETION CITEX ANTI Xa (LMW Heparin) XA FAT SCREEN, STOOL STFAT MYCOPHENOLIC ACID MCPA CORTISOL FREE CORTF ANTI-MITOCHONDRIAL Ab AMA FERRITIN FER MYCOPLASMA IgG, IgM, Abs MYCOP UR PROTEIN ELEC W/TOTAL PROTEIN UELECQ ANTI-SMOOTH MUSCLE Ab ASM FETAL FFN OSMOLALITY, SERUM OSM RANDOM URINE TESTS ANTI-THROMBIN III ANT3 FK 506 FK506 OXCARBAZEPINE METAB OXCAM MICROALBUM / CREATININE RATIO MACR ASO, QUANT ASOQT FOLATE FOLAT PARATHYROID, INTACT PARAT OSMOLALITY, URINE UOSM B-TYPE NATRIURETIC PEPTIDE BNP FSH FSH PARVOVIRUS B19 IgG, IgM Abs PARAB UR IMMUNOFIX W/TOTAL PROTEIN UIFE BETA 2 B2GLB FTA ABS, SERUM FTAS B. PERTUSSIS BY PCR PERRT UR PROTEIN ELEC SCREEN UELECS BK VIRUS, PCR, QUANT BKVQ FUNGAL Ab FUNAB PREALBUMIN PALB BREAST CANCER ANALYSIS - PARAFFIN BLOCK BORDETELLA PERTUSSIS PCR PERRT FUNGUS IDENTIFICATION FUGID PROGESTERONE PROG ERA-ESTROGEN RECEPTOR Ab C. DIFFICILE BY PCR PCRDIF GAMMA GT GGTP PROLACTIN PROL DNA PLOIDY C PEPTIDE CPTD GIARDIA ANTIGEN GIARG PROTEIN C ACTIVITY PRTC HER-2 NEU C REACTIVE PROTEIN CRP GLIADIN IgG/IgA Ab GLIDP PROTEIN C ANTIGEN PRTCA PRA-PROGESTERONE RECEPTOR Ab CA 19-9 CARAG GROWTH HORMONE HGH PROTEIN S ACTIVITY PS CULTURES / MICRO CA 15-3 CA153 HAP PROTEIN S ANTIGEN PSAG INDICATE SITE FOR EACH CULTURE SUBMITTED: CA 27.29 BCAAG HCG-B SUB, QUANT HCGQ PSA PSA CA 125 C125 HCV GENOTYPE, SERUM HCAMP PSA, FREE AND TOTAL PSAFT CHLAMYDIA & GC DNA PROBE CGPRB CARBOXYHEMOGLOBIN COH HCV RNA QUANT PCR HCVRT RAPAMYCIN RAPA CHLAMYDIA DNA PROBE CPRB6 CARDIOLIPIN IgA Ab CIGA HELICOBACTER PYLORI IgG Ab HELP RESPIRATORY ALLERGY PROFILE RSPALG CULTURE, AEROBIC AE CARDIOLIPIN IgG, IgM, IgA Ab ACL HEMOGLOBIN A1C, W/EST GLUCOSE A1CGLU RHEUMATOID FACTOR, QT RFQT CULTURE, ANAEROBIC CULANA CARDIOLIPIN IgG Ab ACLG HEPARIN DEPENDENT Abs (PF4 A, G, M) PF4GMA RBC FOLATE Hct=______RBCFOL CULTURE, FUNGUS FUNG CARDIOLIPIN IgM Ab ACLM HEPARIN DEPENDENT Ab SCREEN PF4G ROTAVIRUS Ag ROTAV CULTURE, TB (AFB) TBC CEA CEA HEPATITIS A AB (IgM) HEPA RPR SCREEN, TITER IF POS RPR GC DNA PROBE (GC ONLY) GPRB6 CELIAC DISEASE PANEL CELAC HEPATITIS - ACUTE HEPATITIS PANEL AHP RSV AG SCREEN, NASO RESSY VIRAL CULTURE, NON RESP VIRNR CRU HEPATITIS A TOTAL AB HAAB RUBELLA IMMUNITY RUBIM O & P (ORDERABLE ONLY IF CHECKED BELOW) PAREX CHILDHOOD ALLERGY MARCH PROFILE MARCH HEPATITIS B CORE AB (IgM) HBAB RUBEOLA /MEASLES IGG AB RUG PRIOR GIARDIA/CRYPTO NEGATIVE CMV IgG, IgM, Ab ECMV HEPATITIS B CORE AB HEPBC SER PROT ELECTROPHORESIS SPE PERSISTENT DIARRHEA COMMON FOOD ALLERGY PROFILE CFOOD HEPATITIS B SURFACE Ab HBSAB SJOGRENS Ab SJOG RECENT TRAVEL OUTSIDE US COMPLEMENT 3 C3 HEPATITIS B SURFACE Ag HBSAG SMEAR, TB (AFB) TBS IMMUNOCROMPROMISED PATIENT COMPLEMENT 4 C4 HEPATITIS C Ab HEPC STONE, KIDNEY ANAL KIDS NEW IMMIGRANT COPPER, SERUM COPPS HERPES SIMPLEX IGG 1 & 2 Abs HSG12 T3, TOTAL T3 TRANSPLANT PATIENT ADDITIONAL TESTS: